Clinical
Reports
Role
of
Nutritional Tropical
Deficiencies Sprue
M.D. AND
in
T.
L. ALTHAUSEN,
M.D., L.
C.
DEMELENDEZ,
E.
PREZ-SANTIAGO,
M.D.
T
the Puerto
disease
HE
purpose
ofthis
paper nutritional tropical is still
is to
appraise deficiencies as
the seen common
blastosis
of latter of typical
the
bone patients
marrow also but such had most as were of intestinal
were
studied. various degrees other anorexia, or absorption not
Eight of
part
played Rico.
on this
by of Sprue
inof
toms of
the
Downloaded from www.ajcn.org by guest on June 6, 2011
pathogenesis
sprue a fairly
looseness in weight
the of and and
bowel sprue
of glossitis, lacking
the
symploss
two
less
decades
frequently
island, although during the past it has been occurring progressively
and usually in a less severe form
steatorrhea results
prominent
tests
were
A
negative.
detailed dietary history covering several years
income prior to the onset of symptoms was obtained from segment of the population is poor but has been each patient in their native Spanish by Mrs. deimproving, especially since the introduction ofMelendez, Chief Dietitian of the Bayam#{243}n Hoslight industry about fifteen years ago. pital. To avoid any defensive bias she made a it with the patients by visiting Whether or not these phenomena have a causal rule to get acquainted several times before the interview during relation has been the subject of debate which them which dietary data were obtained. bears on the concepts of the still undetermined etiology
An aspects history
than
formerly.
The
diet
of
the
low
of
exceptional of and
tropical
tropical nutritional
sprue.
opportunity sprue, including status to study the of victims, its several dietary
The
content
of
each
patient’s
diet
in
calories,
total
protein,
vitamin calcium
protein
C, and iron
of high
thiamine was then
biologic
chloride, calculated.
value,
riboflavin,
vitamin
niacin, values These
A,
presented invited
Army
to
itself spend and
when one a sabbatical
Research
of
us year
(T.L.A.) at the
Laboratory
were compared to was quirements, unless U. S. the 1953 revision
lowances by the from
vitamin
the optimal and otherwise stated,
minimal according
Dietary Council. and
reto
AlThe
Tropical
Medical
of Recommended National Research for the
C,
in San Juan the investigation
at the
arrangements of patients
District Hospital.
AND
were with this
made forminimum taken disease were
Agriculture
those for
requirements Organization standards and Dietary
calories of the the for for build
chloride,
proteins Food Nations,’
riboflavin
publications of
thiamine
the
and
Bayam#{243}n
CLINICAL
United U. S. niacin
MATERIAL
METHODS
The sisted of
these In having From
clinical material of ninety-six hospitalized a diagnosis
were ten men patients anemia Department of Medicine, of
for sprue
and
the
dietetic
in
study
eighty-six
conFifty
and Drug from
calcium from Administration2 the Canadian
of those
Food and
and iron
patients,
Standard.3
Proper
the of of
adsubtropical the Puerto
whom
patients addition,
of
was
thirty-six who were
made.
were
women.
justments of climate
were made and for the the to his
for activity, slighter actual calculated
diagnosed with University megaloof
macrocytic the
of pregnancy Medicine,
Ricans. as As a corollary, was compared
weight
each
patient weight.
“normal”
Data
on
serum
proteins
was
obtained
from
a group
who had before
California School Army Tropical Bayam#{243}n District American Journal
Research Hospital,
San Francisco, Medical Laboratory, Bayam#{243}n, Puerto Nutrition
the
U. and Rico.
patients with tropical sprue S. of twenty-five undergone a detailed laboratory investigation the and after a trial treatment with antibiotics. 3 Vol.
10, January
of Clinical
1962
4
TABLE
Aithausen,
I
deMelendez
the
and
case
Perez-Santiago
of intake of meat which was below
Proportion
of Patients
with
Dietary
Dairy Products All Food stuffs
Deficits
optimum 53 per
None
in 68 per cent of the
incidence of
cent of the women.
suboptimal
men
intake
compared
of vegeta-
to
Subjects
Patients (no.)
Vegetables
Fruits
Meat
The
bles, patients nancy
Table
meat
and
dairy
products
was
higher
in
Patients
wi/Il
.Sprue
Both sexes. Men.... Women.
megaloblastic anemia of pregthan that of female patients with sprue. II shows the breakdown of the dietary obtained nutrients from and patients with a comparison this sprue sprue of allowances table had an and nuof
with
86
50 36
87 87 88
8361
Oil 68
53
lii 24
21 19
6
a
84 81
63
6
data various
into their
Patients
with
.4ne,nia
of
Pregnanty
actual intake and minimum
it is seen
70 20
with the recommended requirements. From our that patients the with intake of thiamine intake of
Women.
10
100
80
that optimal but
60
almost calcium
RESULTS
chloride all other riboflavin in
Table male
i
lists
the with
percentage sprue
of and
male with
patients
trients was suboptimal. The deficiency total and complete protein, and fe- calories, iron was moderate. The deficit megalo- and
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niacin
considerable and that in vitamins A and C blastic anemia of pregnancy whose diet prior towas The average diet of female patients the onset of their diseases was deficient in the marked. higher than that of male patients principal foodstuffs. As shown in the table, was relatively the intake of vegetables, particularly the yellow in calories and proteins and vitamins all studied and green leafy varieties, was below optimum except riboflavin. It was lower only in iron. same table shows that the average diet in S7 per cent of patients with sprue and the The
intake
of
fruits,
chiefly
of
the
citrus
type,
was of
our
patients the
with requirements. dietary anemia with
sprue intake of sprue with
was of is From anemia to those of all
very our
close patients and of with it is pregnancy of patients and nutrients
to
low in S3 per cent. In 61 per contained suboptimal amounts dairy products. According to Research Council recommendations, cent ficient gave mum the of the in all patients principal with sprue foodstuffs, or no
minimum cent the diets the of meat and In Table in megaloblastic the National with female patients 21 per
pregnancy compared this of
had diets de-their but 6 per cent seen than opti- were part in with incalcium.
II
minimum that on sprue patients diets only Their
requirements. comparable in the intake of
a history diet. relative
of optimum Sex played incidence of
better significant
intake
proteins
deficiencies,
except
TABLE
other
Dietary
Intake
of
Eighty-Six
Patients
with
Sprue
Diet
Calories
Total Protein (gin.)
Coni-
plete
Protein
Vitamin
Vitamin
(gm.)
29
40
A (lU.)
C
(mg.)
Thiamine
(lug.)
Riboflavin (mg.)
Niacin (mg.)
Calcium (gm.)
Iron (tug.)
Actual Recommended..
Difference
1,642 2,216
52 64
2,154 5000
29 73
1.1 1.2
1.1 1.5
7.6 12.5
0.74 0.8
9.0 12.1)
-
26
-
29”
-
-8
-27.
-39()
8.2 0.74
25%
Minimum
2(8)7
54
27
2 ,00()
30
1.0
1.2
8.4
Difference
-l8’
4(
+7
-14’
-3
+lO.
-8.
_7e;
0
+7%
Nutritional
Deficiencies
TABLE III
in
Tropical
Sprue
Dietary
Intake
of
Thirty-Six
Female
Patients
with
Sprue
and
Ten
Patients
with
Megaloblastic Anemia
of
Pregnancy
Diet
.
Calories
.
Total Protein (gm.)
Com.
plete
rrotein (gm.)
.
Vitamin
Vitamin
Thia-
Ribo-
A
(lU.)
C
(mg.)
mine
(mg.)
.
flavin
(mg.)
.
Niacin mg.)
.
.
Calcium gm.)
.
Iron mg.
Minimum Actual in withsprue....
1,670 females 1,572
50 51
25 29
2,500 2,370
30 30
1.0 1.4
1.2 1.1
7.0 7.5
0.74 0.74
8.4 8.4
Difference
-6%
+2%
+8%
-5%
0
+40%
8%
+7%
0
0
Actual in patients with anemia pregnancy....
of 1,460 50 21 1,716 20 0.8 0.8 6.2 0.4 9.1
Difference
-13%
0
-8%
-31%
-33%
-20%
-33%
-7%
-46%
+8%
Downloaded from www.ajcn.org by guest on June 6, 2011
was tients
considerably with Iv patients sprue gives
lower and the with
than much percentage sprue
that below
of the of
the minimum male weight
paof
Table after
V
compares
patients
the therapy.
serum
with
protein
sprue before
levels
and
twenty-five
requirements. Table
female whose
antibiotic serum to the albumin expected
Before
treatment low comboth in the Rican albumin of a diet
than
and the waspared
was abnormally normal level States treatment to normal
in
within I () per
over the
the cent
calculated “normal” and whose weight
“normal” by more than
plus was
or minus continental under orrecruits. rose 10 per cent. level the purposely the
“for 75 not underusual it were possible suggestive evidence other than
United During almost
more
and the in
in
Puerto serum spite
respects
The mean
weight. the the was
second deviation
column of the
data Because of keeping to tell These
in
each group
are our track to what
group from
presented patients of their degree
indicates the “normal”
chiefly were weight, the
deficient
all
patients’
per cent diet. probably of
previous
total The protein,
diet.
protein compared changes not a man who our nutritional
It
and to in
contained per62 cent
their serum With had skin showed deficiencies sprue.
only of
average globulin one lesions no
record.” habit impossible
complete in
significant. patients with
weight tion or
Figures blastic meaningless
usually to the
for anemia
present was effects of sprue.
weights of because
TABLE
due
to
undernutriwith megaloobviously state.
exception, of of those pellagra, specific
of of
IV
patients their
pregnancy
are physiologic
associated
&COMMENTS
Nutritional
with Sprue
deficiency,
TABLE
V
as
pointed
out
by
Body
Weight
of
Patients
Normal
Weight
Underweight*
Overweight*
Serum
Proteins
of
(,)
Subjects and No. Patients Deviation Pa tients
(%)
Deviation Patients
(%)
Deviation
.
Patients with Treatment Albumin (gm./100
Sprue
Before
and
After
Subjects
ml.)
Globulin (gin/lot)
ml.)
Both
sexes
(86)
Men Women (50)
30
28
-6
-6
64
72 53
-21
-23
Normal
7
0
4.5
3.0 ± 0.6 2.4 ± 0.6
+18
-..
Puerto
(3b)
32
-7
-18
16
+18
recruits. Sprue (25 patients) Before treatment. After treatment
Rican
.
4.7
.
.
.
3.9
4.4
2. 7
2.9
*
10
per
cent
or
more.
6 Gardner,4
most
Althausen,
is
emphasized
deMelendez
etiologic
on
and
sonnel from
Perez-Santiago
living in continent Puerto Rico relatively than
unknown is predominantly
one other
of
in
the
the
three
literature
factors
tropical
the
who recently
in
had and
arrived were (3)
where
sprue. tion
fats.
The of abnormal
Many
two
are
infection especially
point to
and
metabolites,
observations
a more inges- receiving Sprue is practically rancid
the population
adequate
Jamaica Negro
diet.
and
a connection
between
example the low :
dietary
(1 ) income
deficiencies Sprue is found
segment of
and mostly tropical (2) In
sprue. among areas the in
populations
subsist on a meager diet this disease is prevalent.’7 two decades cidence and
in Puerto considerable
in
Cuban Negroes, no matter how severe For among their dietary deficiencies may be.9 (4) Unenvironmental factors, other than who favorable diet, which result in metabolic stress where faulty
last the observed
with of
a marked reduction severity of sprue had
Rico8 and Cuba9 in the improvement
often active infectious tions, even
provoke sprue.
diseases, alcoholism, emotional own data
the
first Among
or subsequent episodes such factors are
surgical physical that Board in of strain comparison opera-
of inand
been
standard
pregnancy, severe indicate
concomitant
living or
deterioration
in recurrence
these of
in
islands. sprue
the quality
(3) is to
in
The
of the
initial observed
diet
attack
takes An(4) was the
Our
often of
of which (5) Many the
when with Research
ob-majority moderately disdis-plete and deficient portant or near thiamine inpatients). themals of in and that favorable an
the
Food
dietary
and
allotments
Nutrition
recommended
the National
by
Downloaded from www.ajcn.org by guest on June 6, 2011
place,
“explosive” served astrous rupted
e.g.,
in food
incident
increase Puerto supplies.4 Rico of
loss
cases in
a
wake
job.
sprue of seriously
Council
of protein, in dietary optimum chloride In one of us previous our deficient
the
in in
habitual
calories, and niacin and C. present were only found had intestinal B vitamins.’6 a latter A
diets
with total iron. and The
of
sprue and They
a large
were comwere imand female aniunthan
patients
the
hurricane
1932
riboflavin deficient vitamins constituents amounts (the (T.L.A.) on other
authorities,
considerably
markedly only in optimum calcium in the with
such Stefanini,7
the the B of
as
Castle to name
etal.,’#{176}Su#{225}rez,’ Ayrey” but
secondary dietary
a few,
deficiencies
while
factors,
admitting
expressed chiefly
importance opinion components of acid Rico. this and/or palliative folic that
of
volving
causation effective Puerto
complete
are
proteins
largely disease. vitamin treatment Recently
and
(6)
certain
vitamin
for
experiments that much absorption
responsible Administration constitutes sprue of B,2
deficiency more
thiamine effect of several
chloride
Guggenheim
Since
the
recommended
Council
allowances
are rather
of
generous
the
Halevy12
protein
demonstrated
or in proteins
that
of
diets
high
low
biologic
in
cause liver.
ical and diet relatively of poor
a reduction (7)
picture macrocytic of milled the rice rice same eaters
in the was
human anemia with amounts in India
level to
in sprue
of folic reproduce
except monkeys as found whom
acid the
for kept foods in
Research total National value we also compared our patients in the from
the nutritional with minimum by of the the Drug
by our and riboflavin, the itself National be states. protein out diets by the were in during expected on
data obtained requirements and Agriculture Nations,’ the and
In of less protein, and to relative apserum treatbelow comalof requirements gain antibiotic purposely total and iron Council result adein Research The this than the vitarec-
Rao’3
of
able
glossitis in the sprue
clin- promulgated Administration
on
Fiod United
U. a
S.
Food
the A
and
Council intake of total C, by by
Administration2
Nutrition.3 patients complete niacin
the
supplementary among
Canadian diet light amounts is mins ommended
prevalent.
and not
Other observations with the hypothesis tropical sprue: (1)
appear to be inconsistent of dietary causation The disease occurs, although
of would
clinical to
deficiency of the be in while minimum our minimum borne patients their
infrequently, in well-to-do Puerto Ricans who quacy are not food faddists and instances of sprue pears among immediate family members of physicians bumin are one known. cases of (2) Gardner14 tropical sprue in described U. S. twenty- ment Army per- the
requirements
Nutritional
plete studied.
This
Deficiencies
other nutrients
series
in
is
Tropical
rendered
Sprue
more significant by the
7 fact
protein,
leaves
as
only
well
a
as
all
that
moderate deficiency in pregnancy,
men
are
one an the
not
of attack are optimal
subject
the most of sprue
to
the
frequent in
stresses
factors pathoof optimal women.
of
calories, doubtful the intake quate to cause
deficiency.
the in organism
clinical view to of make
significance the element health well an in but signs on known adjustment
of
which ability to
is precipitating of Against thegenesis
of sprue than
predominantly (1) the diets
nutritional finding
of some food for optimum clinically
‘
amounts not low
made- or better enough patients
striking plete ;
6 inper
(2)
cent
the
of our
lack in less of comsimilar victims
with
dietary proteins (3)
this
and the
disease;
B lack vitamins, of a
detectable
of nutritional
deficiencies,
especially among more or
of ing
The bearing of our data tropical sprue is analyzed together
as for
the
and
findings
as
the pathogenesis of sprue further by group- pattern which can be inter- patients;
the nutritional
of
dietary
deficiencies of
in
individual clinical our paantibiotic
preted
against
deficiency
(5)
(4) the absence states other than
the rapid success
specific sprue in
of
deficiency esis are
antedated
:
hypothesis. (1) The
the onset
In finding
of
favor of this that suboptimal
in 94
hypothtients; diets therapy
per cent deficient
with
patients
on
a diet
their
purposely
usual diet;18
more
symptoms
in all
respects than
Downloaded from www.ajcn.org by guest on June 6, 2011
of our dietary ied. dietary themselves
specific
patients intake (2) Even
with sprue was suboptimal though
;
in
21 per cent the( 6) in all items stud- the of the uncovered Puerto
our experience mainland who Rico but
with a suffered to a and
service from without
man from sprue in treatment
none
recovered
deficiencies were sufficiently to produce any of the
clinical deficiencies such
marked inafter being transferred well known West. Approximately to Puerto as scurvy, reassigned par- showed tions periods
eating The vations of vitamins, a result
a post in the Middle year after being Rico this man again laboratory
all three at the the home. obserplayed of be reconciled by part can
ben-ben ticularly
essential often
or those
amino accentuate
pellagra, involving
acids each
such
and other.
deficiencies, proteins
various As
the he
clinical was on
all findings in a error our way. of
manifestaof these
containing
sprue.
During his meals on in opinion,
a substantially
contradictory clinical
similar
diet
practically apparently and sprue, following deficiencies
multiple subclinical nutritional may combine to produce a clinically nonspecific kwashiorkor
The their and generally nutrition of low tene riboflavin greater men versus high serum and kwashiorkor responding with biologic are levels vitamin is number 42 within of per men cent dietary low carotene’8 accepted a a of C; value. deficiency albumin, whereas normal in our women) serum findings relative
deficiencies apparent such sprue.
patients vitamin with a the disease protein of calories A, (4) (58 per serum proteins and level findings
nutritional or possibly
levels invite to in of deficiencies
disturbance tropical
of comparison kwashiorkor, be The due deficiency typical of the limits.’9 series vitamin to our albumin,
as dietary (3)tropical
andin the fundamentally A cor- transmitted
pathogenesis
This
disease
of
probably
a genetically not unlike
is
manifestation metabolism,
that in mal- systems furnish portant in the
origins of The a cent the edge caro- relatively
celiac of energy
nutrients
disease, which the intestinal for
from
affects mucosal
intestinal
the
enzyme cells that of iminto
the
the in
active error
persons
transfer
lumen
blood.
and of the upset
This
common rare in
inborn
others. and
of
of When
metabolism
some national a segment exists underbalance
is
of on is these an
susceptible
population quantitative precarious by any One is a and part of dietary of in are B of amino
habitually qualitative nutritional
is interesting
nutrition in
view
showing versely low in
of the
that affected proteins
experimental
male
work
of
Rosenberg2#{176}easily
more ad- stresses. by diets stresses amino This is
of
the
a
variety
deficiency vitamins acid such great
of
important
metabolic
of of play importance essential
animals are much than female animals of high biologic value.
most
acids deficiencies
which
manifested longevity.
in the rate of growth, The preponderance
adult size and important of males in our These
metabolism.2’
S
In
Aithausen, intestinal absorption rapid mnucosa. others, lining thirty-six in the of calculated the hours. body is small turnover LeBlond that intestine Thus, impaired, because of the
deMelendez of cells the when the entire is renewed protein and
and
in of thenot production
Perez-Santiago
Puerto an Rico absolutely of sprue stress are shows that necessary provided present. that dietary deficiency factor the is inborn
exthe
Stevens,22
ceptionally intestinal
aniong
the in forms
low mciby of nutritional metabolic Among for the flora place. with as seen many pavitapaintake of all female below to condeacid esin the the
metabolic
of metabolic
defect of
States of defect, and peculiar stresses of probably
is pronounced in
is probably a a the to favorable an abnormal occupy of of
III,
and of
accounted incidence good of climate. intestinal
other
The
mucosal every synthesis
dence
sprue
most
limited relatively absence a tropical
the
continental
for
newly United
regenerated
less tive inborn effective task error
mucosal
in which of the is
cells
already
can
be
expected
of the by the
to becombination
absorpgenetic background stresses
performance
handicapped
metabolism.
There
portant abnormal
is
factor
reason
in
to
the
believe
which
that
of
another
sprue interferes which
im- such
is an tablishment with the
conditions a prominent our pregnancy, the of case our their and of our considerably of the anemia considered to by deficiency this various of be of incident consideration dietary patients, clinical to deficiencies stress fails error to is also in deficiencies sprue show
pathogenesis flora’5
intestinal
tropics Dietary
the
similarly sponsible
proper
to
absorption
the Such intestinal for malabsorption stresses the as is
of
essential
flora
nutrients
is
deficiencies anemia
i
patients of
remegaloblastic from nutrients tients me-of calories studied, with is beyond the to is or vitamin probably of with Tables
in
place
the
an
blind
additional
loop
and
in those
Downloaded from www.ajcn.org by guest on June 6, 2011
syndrome. load mucosa tabolism. tional
on
exceeded sprue. and also unlike sprue, requirements. the megaloblastic B,2
female
the
and As deficiencies
already
intensify long
handicapped
initial sum of the the
intestinal
error these results of
Furthermore, of calcium that was scope of
nutri- mins can tients
moderate,
be
as when are
detected
intestinal such intensified by
only
by
biochemical
tests. increase dietary absorption sprue profound of the the findings with by who Ricans its Caribbean of has The the been but trigger fits this diet observation also of rarity the and with of in
means
However, severity demands
such minimum
It or sider ficiencies which and,’ origin
absorption
paper dietary pregnancy a
deficiencies by other than
relation generally
increased
metabolic stresses,
imposed impairment clinical
further to the comits
folic
of intestinal manifestations
leads
nutritional tissue pregfrom of having than did not that and the an form unless even imof our to
triggered these vitamins the
a fall in the
plex
interact that The defect that pernicious parent, the of Spanish Negroes marginal jority the only of recurrence
of
adverse
to produce
nutritional
the transmission by self-perpetuating.
influences
malnutrition metabolic of sprue him suffered had
which reserves
nancy.23 the sprue more Su#{225}rez5 or patients one develop. from when portant pregnancy of the the The large by that other maA detailed before not types eighty-six onset into The from or the pregnancy. In our mean ten genetic point is
The of that with This multiple form of exist,
important view of in these dietary sprue, appears dietary metabolic sprue
becomes genetic is 73
etiology despite
supported per usually cent anemia the Puerto and other patients study. of stress of active pathogenesis the disease. among descent on character
pronounced
of iSo patients investigated mother, It explains
same sprue
prevalence Cubans among
develop present.
metabolic
SUMMARY
islands. a demonstrated
of present
our
dietary of patients patients patients intake with
history symptoms with
covering was tropical
the obtained sprue anemia
period from and of of with of the
onset
worsening metabolic
diet can sprue of
the well disease.
megaloblastic sprue, important allowances a
postulated occasional Puerto
with of dietary
comparison nutrients
occurrence Ricans and
of sprue continental
among Americans
well fed the living the
recommended
Nutritional
National mal amounts Research of The Council calories, indicated total and
Deficiencies
subopticomplete
in
Tropical
FAO
Sprue
Nutritional Rome, the Federal Standard. 2, No. 1958. 1, Tropical sprue. and the 1938. Federal Register, Canadian 1950. New
England
9
Studies 1957. Food, June Drug 1, Bulletin amid 1951. on No. 16.
Nations. Protein
requirements.
protein,
and iron.
vitamins anemia in niost of
sprue. of
A
diets
and
of
C,
patients
riboflavin,
with
niacin
megalo-
2. Section
Cosmetic
403
(j) of
Act. Dietary \ol.
3. Canadian
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